Ops!... Where is my left main?

Coronary artery anomalies can reach easily nowadays elderly age,[1] causing troubles at both diagnostic and therapeutic levels. A 80-year-old hypertensive man underwent coronary artery angiography because of a doubtful ergometric test for atypical thoracic discomfort. The left main was absent in the left coronary sinus (Figure 1A). Selective right coronary artery (RCA) angiography showed a RCA which continued at level of the posterolateral branch with the left circumflex coronary artery (LCx) and retrogradely ended into a left anterior coronary artery (LAD) (Figure 1B and 1C). Left main was clearly agenetic (asterisc, Figure 1C & 1D), whereas LAD and LCx arose with the usual angle. A tight stenosis of the anatomical posteroleteral branch and a mild stenosis of middle LAD were also detected. While atretic left main and single coronary artery have been independently reported,[2]–[3] the combination of both anomalies represents an un-reported coronary arteries vascular pattern. Being the coronary tree a single continuous vessel in this patient, even a tight stenosis of a normally secondary branch as the posteroleratal branch deserves much more attention and prudence than what usually thought, due to the risk of global massive left ventricle ischemia.

Figure 1.

Coronary artery angiography images.

(A): Left coronary Valsalva Sinus angiography in right anterior oblique projection; (B) high selective coronary angiography in the left anterior oblique projection; (C): high selective coronary angiography in the posterior-anterior projection; (D): high selective coronary angiography in the right anterior oblique projection. LAD: Left anterior descending coronary artery; LCx: Left circumflex coronary artery; RCA: right coronary artery.